Tissue Integrity HCC

The nurse is caring for a child with urticaria. What is the priority action?

assessing the child's airway and breathing and noting any wheezing or stridor

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan?

avoiding using deodorant soap on the irradiated areas

A client with urinary incontinence is prescribed incontinence briefs. Which factors should be included in the client education the nurse provides?

"Cleanse the skin each time you change the briefs."

The parent of a 1-week-old infant is concerned with white scales that have begun to flake off the infant's scalp. The parent asks the nurse what to do to treat this. How should the nurse best respond?

"Your child most likely has cradle cap (seborrhea). You can care for it by cleansing the hair and scalp daily with baby shampoo and applying baby oil."

A patient has a moisture-retentive dressing for the treatment of a sacral decubitus ulcer. How long should the nurse leave the dressing in place before replacing it?

12 to 24 hours

A client has a rash on the arm that has been treated with an antibiotic without eradicating the rash. What type of examination can be used to determine if the rash is a fungal rash using ultraviolet light?

A Wood's light examination

The nurse is caring for a diverse group of medical clients. Which client is experiencing adverse effects because their medications do not possess complete selective toxicity?

A client receiving chemotherapy who has developed mucositis.

During a breast examination, which finding most strongly suggests that a client has breast cancer?

A fixed nodular mass with dimpling of the overlying skin

Most of the body's hair follicles are paired with which anatomical part?

A sebaceous gland

What desired effect can the nurse expect after administering an antihistamine to a pediatric client with a disorder of the skin?

decreased itching less skin irritation

The practitioner examines his client's foot and observes the great toe to be black and dry. The practitioner explains to the client that the dead tissue is caused by:

dry gangrene.

A group of students is reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast?

Better molding to the client

While breaking in a new pair of shoes, a client develops a large (1 cm) lesion filled with clear fluid. Which term will the health care provider document in the client's chart?

Bullae

The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?

contact

The nurse is caring for a child with an intravenous device in the hand. Which sign would alert the nurse that infiltration is occurring?

cool, puffy skin

A 14-year-old girl has been thrown from the back of a pick-up truck. MRI shows complete cord injury at the level of C2. What is the main significance of an injury at this level of the spinal column?

Cannot breathe on own, needs ventilator assistance

The nurse is caring for a 22-year-old client with a circumferential burn to the left thigh. What assessment should the nurse perform as a priority specific to this type of burn?

Color, warmth, circulation, sensation, and movement of the left lower leg and foot

A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

Develop a written, individual turning schedule.

A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. What should the nurse should advise the client to do during the 2-hour car ride?

Do ankle pumps.

Plantar warts may be treated with which of the following modalities?

Electrodesiccation

A teenager is admitted to the burn unit with third-degree burn injuries over more than 40% of the body. When administering I.V. fluids to the client within the first 48 hours of injury, what is the most important responsibility of the nurse?

Ensure a fluid volume sufficient to prevent shock.

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:

Epidermis and a portion of deeper dermis.

Parents of a 20-month-old infant report that he refuses food or eats poorly and that he grimaces when he swallows. He also is irritable and cries a lot. The mother is worried that he ate something inappropriate this morning, because he vomited something that looked like coffee grounds. Which health problem would the care team first suspect?

Esophagitis from gastrointestinal reflux

Hematoma and seroma formation are complications of breast surgery. Which of the following is the indicator that should be reported to the surgeon?

Gross swelling

A client fell off his motorcycle, receiving several large abrasion-related surface wounds. What physiologic phenomenon will the client first experience?

Healing by secondary intention

A nursing instructor is preparing a class on pressure ulcers. Which of the following would the instructor most likely include as a possible risk factor?

Increased moisture Immobility Anemia

In which client with a transecting spinal cord injury should the nurse anticipate an impaired ability for temperature regulation?

Injury at T2

For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?

Inspecting the skin for petechiae once every shift

The nurse is assessing a 3-year-old boy with Sturge-Weber syndrome. Which finding is most indicative of the disorder?

Inspection reveals a port-wine stain.

A client with chronic renal disease has severe pruritus. Which interventions should the nurse include in the teaching plan for the client?

Keep fingernails trimmed Moisturize the skin frequently Take a cool shower before bed

Which related circulatory complication can result from surgical treatment for metastatic breast cancer?

Lymphedema in the affected arm

The nurse is caring for an older adult patient experiencing fecal incontinence. When planning the care of this patient, what should the nurse designate as a priority goal?

Maintaining skin integrity

A client has sought care for a serious sunburn that resulted from falling asleep at the beach. What physiologic process was involved in the client's overexposure to ultraviolet radiation?

Melanocytes were unable to sufficiently protect that client

A nurse assesses a client with a 3-cm lipoma in the subcutaneous tissue. Which term would best describe this lesion?

Nodule

Which term refers to the failure of fragments of a fractured bone to heal together?

Nonunion

The nurse knows that a client with chronic kidney disease (CKD) may experience which changes in skin integrity?

Pale skin Decreased perspiration Brittle fingernails

A nurse is caring for a client who is admitted from home to a long-term care facility. During the admission assessment, the nurse documents a stage II pressure ulcer and places a referral to the enterostomal therapist (ET). When gathering supplies for a stage II ulcer, what characteristics would the ET anticipate?

Partial-thickness skin loss of the epidermis is evident. Undermining is present. Undermining is present.

Which anatomical site would the nurse expect to monitor when caring for an adult client who has just had a bone marrow aspiration performed?

Posterior iliac crest

Which intervention is best to use with the 6-year-old who has developed stomatitis as a side effect of chemotherapy?

Practice frequent, gentle oral hygiene

Which are considered functions of the skin?

Protection against physical injury Protection from an invasion of microbes Synthesis of vitamin D

A nurse completes an assessment on an 8-month-old infant seen in the pediatrician's office for a well-child visit. The nurse notes that the infant's buttocks, perineum and inner thighs are covered in a thick coating of white ointment. When questioned, the parent says the infant has a diaper rash and the ointment is to protect the infant's skin. What is the best action for the nurse to take?

Provide instruction on how to care for a diaper rash

Photochemotherapy has been used as a treatment for which of the following skin disorders?

Psoriasis

Regurgitation of bile salts and duodenal contents can lead to gastric ulcers. Which structure prevents this from happening?

Pyloric sphincter

The nurse is instructing a client who is at risk for peripheral artery disease how to use knee-length elastic stockings (support hose). What instructions should the nurse include in the teaching plan?

Remove the stockings every 8 hours, elevate the feet, and reapply in 15 minutes. Apply the elastic stockings before getting out of bed.

The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal?

Retinal Angiography

Which nursing diagnosis will the nurse prepare for the infant who is placed prone to protect the myelomeningocele repair site?

Risk for impaired skin integrity

Aortic aneurysms take varied forms and can occur anywhere along the aorta. What are the types of aneurysm termed abdominal aortic aneurysms?

Saccular aneurysms Fusiform aneurysms

The nurse is assessing a patient's pressure ulcer and notes a full-thickness wound that extends into the subcutaneous tissue. Necrosis and infection are present. The nurse documents this ulcer as which stage?

Stage III

A teenager asks advice from a nurse about getting a tattoo. When the nurse is providing education, which statement about tattoos is a common misconception?

Tattoos are easily removed with laser surgery.

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion?

Tearing of a structure from its normal position

A newborn is suspected of having gastroschisis at birth. How would the nurse differentiate this problem from other congenital defects?

The intestines appear reddened and swollen and have no sac around them.

The nurse is caring for a neonate with an exstrophy of the bladder. When the nurse is planning care, which client goal is the priority?

The neonate will be free from infection.

The spinal cord does not hang freely within the spinal column. What is it supported by?

The pia mater and the denticulate ligaments

Which congenital condition is an immediate emergency requiring notification of the health care provider?

Tracheoesophageal fistula

The nurse examines a patient and notices a herpes simplex/zoster skin lesion. How does the nurse document this lesion?

Vesicle

When caring for a postoperative client, in order to promote wound healing, which of these nutrients does the nurse encourage the client to consume?

Vitamin C

The nurse is selecting a dressing for a vascular wound that has a dry wound surface. The most appropriate dressing for this wound is one that:

adds moisture to wound bed.

A client has a Staphylococcus infection in a decubitus ulcer. In this case, Staphylococcus is the:

agent

A client's risk for the development of a pressure injury is most likely due to which lab result?

albumin 2.5 mg/dL

A client will be receiving a bone graft from an unrelated individual. Which type of graft does the nurse inform the client that he or she will be receiving?

allograft

A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin

enhances protein synthesis.

The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of:

fissure

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?

fourth degree

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?

lactated Ringer's solution

A client is admitted with a risk for skin breakdown and states to the nurse, "I haven't been eating healthy for the last few months." What would the nurse look for to confirm this risk factor?

muscle wasting obesity loss of subcutaneous tissue

Which assessment finding is the priority to report for a client who recently underwent a vaginectomy?

pain and frank red blood at the client's rectum

The skin covers the body, and it is exposed to a number of potentially damaging agents in the external environment. What effect(s) do ultraviolet rays of sunlight have on the skin?

predisposing to the development of skin cancer causing potential for directly damaging the skin accelerating the effect of aging on the skin

A continuing education nurse in a long-term care facility is discussing wound healing in older adult clients. Because older adult clients are more likely to have comorbidities like problems with mobility, diabetes, or vascular problems, the nurse should assess the clients for which condition(s)?

pressure injuries on buttocks ischemic ulcer formation in feet impaired healing related to diabetes

Which action could result in pressure injury formation?

pulling a client up in bed

Which congenital condition leads to the infant being hungry, irritable, losing weight, and rapidly becoming dehydrated with the potential of metabolic alkalosis?

pyloric stenosis

A client has a history of dislocations of the same joint. The nurse understands that this is most likely due to an insufficient deposit of collagen during the healing process, leading to:

reduced tensile strength.

Following a severe automobile accident, a client is scheduled to have surgery to either repair or remove his spleen, pancreas, and stomach. The client wants the organs repaired and not removed if at all possible. However, the nursing staff understands that extensive regeneration in parenchymal organs can only occur if:

the residual tissue is structurally and functionally intact.

A client has developed Kaposi's sarcoma. What defense mechanism is the most affected by this homeostatic change initially?

the skin is affected

While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at her daughter's home with six other people. During her visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:

"All family members need to be treated."

The gastrointestinal laboratory nurse is learning about small intestine secretions. Which explanation is most accurate?

"An extensive array of mucus-producing glands, called Brunner glands, is concentrated where contents from the stomach and secretions from the liver and pancreas enter the duodenum."1

A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. What is the appropriate teaching by the nurse to prevent skin damage?

"Apply sunscreen even on overcast days."

A client seeks medical care for severe sunburn. Which teaching should the nurse provide to reduce the client's risk of skin damage from sun exposure?

"Apply sunscreen even on overcast days."

A parent calls the health care provider about the 7-year-old child's dental hygiene. The child has had three cavities. The parent does not know what to do and asks the nurse for guidance. How should the nurse respond?

"Are you able to supervise your child's brushing?"

The nurse is caring for a mom and her baby on a postpartum unit. The mom states she has received advice not to use baby powder on newborns. She asks the nurse if this is true, and if so, why. Which nurse response is correct?

"Baby powder should not be used on newborns due to the risk of aspiration upon application."

Select the statement that best describes the formation of a keloid.

"Benign, tumor-like mass"

The nurse assesses a client's skin and finds an elevated palpable mass with a circumscribed border. How will the nurse chart this finding?

"Client has a papule."

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?"

The nurse is evaluating the parents' understanding of atopic dermatitis. Which statement shows their understanding?

"Flare-ups of lesions are not uncommon following therapy."

A client who has a diagnosis of lung cancer is scheduled to begin radiation treatment. The nurse knows that which statement about potential risks of radiation is most accurate?

"Some clients experience longer-term irritation of skin adjacent to the treatment site."

The nurse is caring for a 2-month-old infant. The parent asks if it is okay to use a sunscreen lotion made for children. Which response by the nurse would be most accurate?

"Sunscreen is not recommended until 6 months of age. Use light clothing and a hat to completely cover the child when in the sun."

A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?

"The client remains free of signs and symptoms of phlebitis."

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

As part of a first aid class, a health care instructor is teaching a group of industrial workers about how electrical injuries can cause cell damage. Which statement made by one of the workers indicates that further teaching is necessary?

"The greater the skin resistance, the greater the amount of deep and systemic damage a victim is likely to incur."

The nurse instructor is reviewing the integumentary system during a presentation to a group of student nurses. Which statement made by the instructor is the most accurate regarding the integumentary system?

"The largest organ of the body helps regulate body temperature."

A client with new-onset herpes zoster (shingles) asks the nurse, "Why is this rash just on my face?" Which response by the nurse is most accurate?

"This virus was reactivated and travels from the ganglia to the skin of the corresponding single spinal nerve like your face."

A newborn has a generalized rash on the skin, which the nurse identifies as erythema toxicum neonatorum. Which information would the nurse include when explaining the condition to the newborn's parent?

"What you see on your newborn's skin is erythema toxicum neonatorum. It is a common newborn skin condition that typically resolves on its own in about 1 week. There is nothing special you will need to do for this."

A client is being seen in the primary care physician's office for a follow up appointment for a second-degree burn. The burn is healing. In approximately what time frame do second-degree burns maintain their softness and elasticity but may have loss of sensation with scar formation?

1 month

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

36%

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?

36%

A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours?

80 to 120 mL

The nurse is caring for a client with arterial insufficiency of the left leg with gangrenous wounds on the second and third toes. What characteristics of the wounds should the nurse evaluate as expected?

A clear demarcation between the healthy and affected tissue Diminished pulse strength Darkened appearance of affected tissue Atrophy to the affected toes

A clinician who works on a cardiac care unit of a hospital is providing care for a number of clients. Which client most likely has a genetic disorder arising from inheritance of a single gene?

A tall, thin, myopic, 28-year old woman with mitral valve prolapse

The nurse is developing the plan of care for a child who has suffered a major burn and has just been admitted to the acute care facility. Which nursing diagnosis would be most appropriate?

Acute pain related to thermal injuries and procedures

What nursing intervention helps reduce itchiness or prevent the client from scratching the skin would you institute with a client who has an allergic reaction and tends to itch due to histamine release?

Advise the client to use distracting techniques.

When is it advisable for the nurse to apply heat to a sprain or a contusion?

After 2 days

A client is seen in the primary care office with eczema. What is the best description to include in the electronic medical record about the skin assessment?

An acute, red, itchy, vesicular crusted lesion

When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk?

Anemia Edema Diaphoresis (sweating)

Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation?

Anticoagulant

An ileal conduit is created for a client after a radical cystectomy. Which of the following would the nurse expect to include in the client's plan of care?

Application of an ostomy pouch

The nurse is instructing the patient in how to apply a corticosteroid cream to lesions on the arm. What intervention can the nurse instruct the patient to do to increase the absorption of the medication?

Apply an occlusive dressing over the site after application.

A school-aged child is brought to the office of the camp nurse with a small, superficial burn (first-degree burn). Which action by the nurse would be most appropriate to take first?

Apply cold compresses to the area.

The camp nurse is caring for a child who was bitten on the leg by a dangerous spider. The child is being taken to a health care provider. What is the most appropriate action for the nurse to do with this child?

Apply ice to the affected area.

A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following?

Arterial insufficiency

A client is diagnosed with an abdominal aortic aneurysm that the physician just wants to "watch" for now. When teaching the client about signs/symptoms to watch for, the nurse will base the teaching on which physiologic principle?

As the aneurysm grows, more tension is placed on the vessel wall, which increases the risk for rupture.

A client presents with peripheral neuropathy and hypoesthesia of the feet. What is the best nursing intervention?

Assess for signs of injury.

Which cell types are responsible for repair and scar formation (also called gliosis) in the brain?

Astrocytes

Which term refers to a graft derived from one part of a client's body and used on another part of that same client's body?

Autograft

A nurse is triaging clients at a disaster site. Local facilities have different specialized units. To what facility should the nurse send a client who has sustained an electrical injury to his left thigh?

Burn unit

There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway?

Cervix

A client with diabetes and peripheral neuropathy is being discharged from the hospital. What instruction should the nurse provide to decrease the risk for skin breakdown?

Check the feet daily to look for any injuries. Always wear socks and, preferably, shoes to protect the feet.

The nurse should teach the patient who is being radiated about protecting his skin and oral mucosa. An important teaching point would be to tell the patient to:

Cleanse the skin with a mild soap, using his fingertips, not a rough wash cloth.

A nurse reading a sigmoidoscopy report notes that a client was found to have skip lesions. The nurse interprets this as an indication of:

Crohn disease

A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. What is the best action by the nurse?

Evaluate client protein levels.

A client from a nursing facility arrives with fever of unknown origin. On assessment, the nurse notes a wound on the coccyx documented as: Full thickness tissue loss with exposed bone, tendon, or muscle. Which skin lesion description is most appropriate to report to the health care provider?

Extensive damage with tissue loss due to a pressure injury

A nurse is performing an otoscopic examination on a client. Which finding would the nurse document as abnormal?

External auditory canal erythema

There are two pathways that can be activated by the coagulation process. One pathway begins when factor XII is activated. The other pathway begins when there is trauma to a blood vessel. What are these pathways?

Extrinsic and intrinsic pathways

After falling off his bicycle, an 8-year-old boy has a large abrasion on his posterior thigh that has removed the epidermis in the region but left the dermis largely intact. Which change in integumentary system would be expected in the area of his wound?

Fewer Merkel and Langerhans cells in the region

When caring for a client during the proliferative phase of wound healing, the nurse teaches the client that which of these processes is taking place?

Fibroblasts secrete collagen for wound healing.

A client has just been diagnosed with cirrhosis and has been told he needs a transplant. What changes have occurred in the liver due to cirrhosis that results in an inability to heal and require transplant?

Fibrosis has occurred and there are constrictive bands that disrupt biliary flow.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

First intention

The nurse is developing a plan of care for a client with toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome. Which action should the nurse include?

Frequently inspect the oral cavity.

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following?

Full-thickness

Which describes a stage III pressure injury?

Full-thickness skin loss involving damage and necrosis of subcutaneous tissue that may extend down to but not through underlying fascia

The nurse is explaining Rh factors to a client who will receive a blood transfusion. How should the nurse best describe histocompatibility antigens?

Genetically determined markers for self-cell identification

A client has been told he has abdominal adhesions due to an old appendix infection. Knowing the structures of the abdominal cavity, the nurse will explain about which structure that can form bands of fibrous scar tissue to wall off the infection, preventing it from spreading to other parts of the body?

Greater omentum

Dry, itchy plaques on the elbows and knees have prompted a 23-year-old client to seek care. The health care provider has diagnosed the client with psoriasis, based on which histologic characterization?

Increased epidermal cell turnover with marked epidermal thickening

An 80-year-old woman has had abdominal surgery following a bowel obstruction. The nurse is aware that the recuperation period for this patient will most likely be prolonged due to what common condition found in the elderly?

Increased time for healing

A client with a history of several previous abdominal surgeries has been admitted to the hospital with severe abdominal pain. Knowing that adhesions can form following abdominal surgery, what assessment should the nurse focus on?

Intestinal obstruction causing constipation

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?

Ischial tuberosity

Which of the following is the effect of protein catabolism in a client with severe burns?

It compromises wound healing and immunocompetence.

A client with fibrocystic breast disease has been receiving treatment with danazol (Danocrine) therapy for the past 6 months. In anticipation of the drug being discontinued, the nurse instructs the client to inform the health care provider about which of the following?

Lack of return of regular menses within 90 days after discontinuing the drug.

A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic?

Larger than 1/4 inch in diameter Change in the mole Irregular edges

A client arrives at the clinic and informs the nurse that there is an "itchy rash" on his face. Which type of deficiency should the nurse suspect that may have caused dermatitis in this client?

Linolenic acid

A client has been admitted to the hospital with an exacerbation of peptic ulcer disease. The nurse is aware the client is at risk for:

Perforation Obstruction Hemorrhage

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client?

Perform range-of-motion exercises. Encourage the client to eat a well-balanced diet. Reposition the client every 2 hours.

Hyperbaric treatment for wound healing is used for wounds that have problems in healing due to hypoxia or infection. It works by raising the partial pressure of oxygen in plasma. How does hyperbaric oxygen treatment enhance wound healing?

Promotion of angiogenesis

Phosphate excretion is impaired in chronic kidney disease (CKD), resulting in high serum phosphate levels and the development of phosphate crystals. Which manifestation of hyperphosphatemia should the nurse assess for?

Pruritus

A client who presented with shortness of breath and difficulty climbing stairs has been diagnosed with pulmonary fibrosis, a disease characterized by scarring of the alveoli. Upon assessment of the lungs, what clinical manifestations should the nurse expect?

Short, shallow breaths.

The nurse assists and educates clients on the difference between nonspecific and specific immunity. The body possesses several defense systems. Which nonspecific defense mechanism provides a physical barrier and secretes enzymes that kill or reduce the virulence of bacteria?

Skin

A 79-year-old man is scheduled for surgical repair of an inguinal hernia. In light of this patient's age, the nurse will prioritize nursing interventions aimed at preventing:

Skin breakdown

Which conditions or events commonly trigger nociceptive pain?

Surgery Osteoarthritis Chemical burn

Which responsibility of the extracellular matrix (ECM) is most accurate?

The ECM provides the scaffolding for tissue renewal.

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?

The pinna of the ear is soft and flat and stays folded.

The community health nurse is preparing a presentation which will illustrate the various forms of spina bifida for a health fair. Which explanation should the nurse use to explain spina bifida with meningocele?

The spinal meninges protrude through the bony defect and form a cystic sac.

The nurse is assessing a client with diabetes and notes an area on the client's right foot as inflamed, necrotic, and eroded. The client states he accidentally slammed his foot in a door 2 weeks ago. The nurse would document this finding as a(n):

Ulceration

When bathing a client, the nurse notices that the client has a rash on her arms. What would be an appropriate nursing intervention?

Use a tepid bath to relieve inflammation and itching.

While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client?

Use an electric razor when assisting client with shaving.

The nurse is caring for a pediatric client with multiple wounds from a bike accident. What is the best method for cleansing or washing out the wound?

Use normal saline solution to wash the wound.When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk?

A skin care consultant informs the client that he needs to bathe and use a soft cloth to remove dead cells on the skin surface. The rationale for this action is based on the fact that:

a basal cell is mitotically active and pushes older dead cells to the skin's surface.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

a surgical incision with sutured approximated edges

The nurse is reviewing a client's daily labs. Which lab report would concern the nurse related to the client's risk for skin breakdown?

albumin

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes

Severe head trauma from a coup-contrecoup injury may result in which type of brain injury?

cerebral hematoma

A woman seen in the emergency department is diagnosed with primary syphilis. What finding is most likely?

chancres at the vaginal site

A client is brought to the emergency department after being struck with a baseball bat on the upper arm while diving for a pitched ball. Diagnostic tests reveal that the humerus is not broken but that the client has suffered another type of injury. What type of injury would the physician likely diagnose?

contusion

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

corticosteroids

A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area?

escharotomy

Caregivers of a toddler report poor oral intake and grimacing when swallowing. The caregivers also describe the toddler as having difficulty with sleep and wheezing being heard when breathing. The nurse focuses initial assessments based on which likely cause of the symptoms?

gastrointestinal reflux disease

Clients with chronic liver dysfunction have problems with insufficient vitamin intake. Which may occur as a result of vitamin C deficiency?

scurvy

A child comes in to show his parents (who are nurses) a blister on his foot from "breaking in" a new pair of shoes. The child wants to "pop the blister" to get all the fluid out of it so it won't hurt so much when he puts on shoes and socks. The parents know that breaking the skin of the blister will put him at risk for:

secondary infection.

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?

secondary intention

A client has been diagnosed with systemic lupus erythematosus, a disease that affects the structure and function of collagen. The nurse should expect to assess this client for:

signs of connective tissue weakness.

A nurse is changing a client's surgical incision dressing on post-op day three. For which observation would the nurse take immediate action?

small amount of creamy yellow drainage

The nurse is caring for a woman with a labial carbuncle. Which intervention will most likely be included in the plan of care?

soaking in a warm bath for drainage

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

stage II pressure ulcer

A young child has recently developed macules on the trunk, extremities, and mucous membranes. The child is mildly febrile, but the primary symptom is extreme pruritus. What disorder of the skin most likely is the cause of this child's condition?

varicella

The nurse provides teaching on postoperative wound care to a client being discharged from a surgical unit. Which statement documented by the nurse indicates that the client understood the teaching?

"Client verbalized to the nurse the steps to follow if wound becomes red and warm."

The nurse is providing education to the parent of a male diagnosed with Marfan syndrome. The nurse knows that her teaching has been effective when the parent states which of the following?

"His participation in sports may need to be limited."

Which of these clients' statements would be most suggestive of retinal detachment?

"I feel like there's a shadow that's blocking my vision."

The school nurse has completed an educational program on first aid practices in the home. Which statement about burn care by a participant would indicate a need for further education?

"I guess my mom was right; she always put ice on our burns when we were kids."

A topical corticosteroid is prescribed for a child with contact dermatitis. Which statement by the mother would indicate the teaching was successful?

"I should not cover the area with plastic wrap after applying the cream."

A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding?

"I'll eat plenty of fruits and vegetables."

Which statement indicates that a client with diabetes mellitus understands proper foot care?

"I'll wear cotton socks with well-fitting shoes."

An adolescent is diagnosed with psoriasis. After speaking with the nurse about treatment options suggested by the primary health care provider, the adolescent states, "Since ultraviolet rays help, I am going to buy a tanning package so I can tan year round." How will the nurse respond?

"Year round tanning is not what your health care provider intended. Tanning puts you at high risk for skin cancer and other problems."

A parent expresses a concern about white scales that have begun to flake off the 1-week-old infant's scalp. The parent asks, "What can I do to prevent this?" Which response by the nurse would be most appropriate?

"Your child most likely has cradle cap (seborrhea). You can care for it by cleansing the hair and scalp daily with baby shampoo and applying baby oil."

A group of nursing students are studying the process of hemostasis and determine that there is a specific order of events.

- Vessel vasoconstriction - Platelet plug formation - Blood coagulation - Clot retraction - Thrombolysis

A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanel (fontanelle). The client is anxious to know when the posterior fontanel (fontanelle) will close. Which time span is the normal duration for the closure of the posterior fontanel (fontanelle)?

8 to 12 weeks

A client is postoperative following a graft reconstruction of the neck. What intervention is the most important for the nurse to complete with the client?

Assess the graft for color and temperature.

The nurse is caring for a 6-year-old boy with Russell traction applied to his left leg. Which intervention would be most appropriate to prevent complications?

Assess the popliteal region carefully for skin breakdown.

The gastric mucosal barrier works to prevent acids secreted by the stomach from actually damaging the wall of the stomach. What are factors that make up the gastric mucosal barrier?

Characteristics of gastric mucus Mechanisms for selective transport of hydrogen and bicarbonate ions An impermeable epithelial cell surface covering

A health care provider suspects a client has developed diverticular disease. Which diagnostic test is usually prescribed to confirm the diagnosis?

Computed tomography (CT) scan

A nurse is providing care to a child with partial and full thickness burns over 26% of the body. In monitoring the child's output the nurse expects an output of 1 to 2 mL/kg/hr. The nurse has emptied 46 ml from the foley catheter for the past hour. The child weighs 62 lb (28 kg). What action should the nurse take?

Document the output and continue to monitor.

A client goes to the health care provider following several days of nausea/vomiting and abdominal pain. After assessment, the provider thinks the client has Helicobacter pylori (H. pylori) infection. Which complications of H. pylori should the client be educated about if this infection is not eradicated?

Gastric cancer due to metaplasia changes in the cells GI bleeding due to peptic ulcer formation

A client is experiencing reflux of stomach contents into the esophagus. The nurse determines that the problem may result from:

Gastroesophageal sphincter

A patient is told that she has a common form of breast cancer where the tumor arises from the duct system and invades the surrounding tissues, often forming a solid irregular mass. What type of cancer does the nurse prepare to discuss with the patient?

Infiltrating ductal carcinoma

A client sees a dermatologist for a skin problem. Later, the nurse reviews the client's chart and notes that the chief complaint was intertrigo. This term refers to which condition?

Irritation of opposing skin surfaces caused by friction

Which infecting agent causes scabies?

Itch mite

While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the liklihood of liver problems?

Jaundice Petechiae Ecchymoses

The nurse is performing a physical examination of a patient and observes a well-healed old scar on the right shoulder. The scar is hypertrophied, elevated, and irregular without any redness or irritation. The patient states, "I had shoulder surgery about 5 years ago." The nurse documents this finding as which of the following?

Keloid

A patient has contact dermatitis on the hand, and the nurse observes an area that is thickened and rough between the thumb and forefinger. What does the nurse know that this is significant of related to repeated scratching and rubbing?

Lichenification

A nurse in a healthcare provider's office teaches a client how to apply plastic film as an occlusive dressing to cover a medicated ointment applied to the arm. What important teaching point would be included by the nurse?

Limit use of the dressing to 12 hours.

Diverticulitis is the herniation of tissue of the large intestine through the muscularis layer of the colon. It is often asymptomatic and is found in approximately 80% of people over the age of 85. Diverticulitis is often asymptomatic, but when symptoms do occur, what is the most common complaint of the client?

Lower left quadrant pain with nausea and vomiting

The nurse is teaching the client with chronic venous insufficiency. Which part of the body is particularly prone to development of stasis dermatitis?

Lower leg

A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address?

Moisture

A client with a history of peptic ulcer disease presents to the emergency department with the following symptoms: early satiety, feeling of epigastric fullness and heaviness after meals, weight loss, and vomiting. The nurse suspects that the peptic ulcer has caused which problem?

Obstruction

The nurse is caring for a neonate with epispadias. In which location will the nurse assess the anomaly?

On the dorsal end of the penis

A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see?

Peeling hands and feet; fever

While studying the skin in a science class, a student asks why all people have a pinkish color to their lips/mucous membranes. The instructor would respond by stating:

Pheomelanin is the yellow to red pigment particularly concentrated in the lips and nipples in humans.

A young lifeguard has been prescribed moxifloxacin (Avelox). The nurse understands that the focus on education would be which adverse reaction?

Photosensitivity

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?

Pink to red and soft, bleeding easily

A client with a pilonidal sinus undergoes surgery. Which of the following would the nurse include in the client's postoperative plan of care?

Repacking the surgical wound

The first-line treatment for dry skin is moisturizing agents. How do these agents work?

Repairing the skin barrier

A client has a burn that involves the entire epidermis and various degrees of the dermis. It is painful, moist, and blistered. The nurse recognizes the burn as:

Second-degree partial thickness

Mitosis that results in the production of new epidermal cells occurs in which layer of the epidermis?

Stratum germinativum

Which type of nervous system response can cause a marked decrease in mucous production, leaving the area susceptible to irritation, thereby causing ulcer development in the duodenum?

Sympathetic stimulation

Painless chancres are associated with which systemic disease?

Syphilis

The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins?

The cervix is softening

Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized?

The client's skin is intact with non-blanchable redness of a localized area over a bony prominence.

The nurse is preparing a client to have his cast cut off after having it for 6 weeks to treat a fractured tibia. What should the nurse inform the client prior to the cast being removed?

The skin may be covered with a yellowish crust that will shed in a few days.

The nurse is caring for a client with an infected wound that is left to heal by secondary intention. Which observation does the nurse expect to make during assessment of the wound area?

The wound is healing slowly with epithelial and scar tissues present.

When caring for a client with primary biliary cirrhosis, which of these statements by the nurse will best teach the client about the cause of this problem?

There is autoimmune destruction of the bile ducts.

A postpartum woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give?

Wash her perineum with her daily shower.

The nurse on the elective surgery floor receives a report that describes the client's abdominal wound dressing as having a moderate amount of yellowish and bloody drainage on it and a very foul smell. In planning for a dressing change, it is most important for the nurse to perform which action?

Wash the nurse's hands before and after the dressing change.

Metalloproteinase requires which mineral to be present before degradation of collagen occurs?

Zinc

The nurse is providing care for several clients on a medical-surgical unit. Which client's health problem is the most direct result of lysosome action?

a client with a sacral pressure ulcer that is worsening

A client with diabetes has an admission hemoglobin A1c (HbA1c) level of 13 (goal is 6) and an abdominal wound that will not heal. The nurse knows that hyperglycemia (poor blood glucose control) has an effect on wound healing, especially related to neutrophils affecting:

ability to engulf and kill bacteria because of poor phagocytic function.

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical?

amniotomy

The nurse is caring for a diverse group of clients. Which client is most likely to require education about the role of histocompatibility antigens?

client with chronic renal failure who will soon receive a kidney transplant

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for:

dehiscence.

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action?

elevating and supporting the stump

A 42-year-old female client complains of extreme xerosis and states nothing seems to work for her skin. The most appropriate treatment would be to apply:

emollients or occlusives, as they are the most effective treatment.

A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include

ground beef patties.

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action?

handwashing before leaving the client's room

Which cellular structure would most likely be involved with organ transplantation?

histocompatibility antigens

When assessing a child for impetigo, the nurse expects which assessment findings?

honey-colored, crusted lesions

The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication?

hyperbilirubinemia

The nurse is presenting an in-service to a group of nurses who will be working in a dermatology clinic. One participant asks the nurse about a bacterial skin infection that she has seen in children that involves honey-colored crusted lesions. The nurse most likely is referring to:

impetigo.

An infant who is diagnosed with meconium aspiration displays which symptom?

intercostal and substernal retractions

A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake which foods should the nurse emphasize?

lean meats and low-fat milk

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects:

melanoma

The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity?

moving the infant's head every 2 hours

A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. After surgery, the nurse implements measures to prevent complications. Which complications is the nurse seeking to prevent?

pneumonia wound infection skin breakdown

When determining the half-life of a drug, what must be taken into account?

rate of absorption distribution to the tissues excretion rate

After many years of cigarette smoking, a client is admitted to have a "mass" removed from the lung. When explaining the surgery and recovery, the physician notes that the client is likely to have a good amount of fibrosis develop at the surgical area. After the physician leaves the room, the client asks the nurse what was meant by "fibrosis" in the lung. The nurse bases the response on the fact that tissue repair can:

result in replacement tissue in the form of connective (fibrous) tissue, which leads to scar formation or fibrosis of the lung.

The nurse is working in a rehabilitation facility with a paraplegic client who generally spends the day out of bed in a wheelchair. Which exercises will the nurse help the client perform to reduce the risk of skin breakdown?

shifting weight from side to side arm push-ups

The nurse is caring for a client with a percutaneous tube with an external retention flange. The nurse notifies the healthcare provider that the tension on the retention flange is excessive upon discovering what assessment finding?

skin breakdown at the stoma site

The nurse is caring for a 7-year-old with burns. Which finding would be highly suggestive of a burn induced by child abuse (child maltreatment)?

stocking-glove pattern on hands or feet

The nurse admits a child who has sustained a severe burn. The child's immunizations are up to date. Which immunization would the child most likely be given at this time?

tetanus toxoid vaccine

The nurse notes bulging and separation of an abdominal incision while assessing a client. What is the purpose of applying a binder?

to reduce stress on the abdominal incision

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room?

transparent

A client with a major burn injury is receiving fluid resuscitation. Which assessment finding indicates that this treatment has been effective?

urine output at 0.5 mL/kg/hour